Health Plan Management Method and Apparatus

ABSTRACT

Techniques and apparatus for managing contributions to an accruable health spending account in an employer-sponsored plan offering a member an employer-funded defined contribution, at least one insurance premium option and the ability to specify an allocation of the defined contribution for payment of option premiums and in turn, a directed contribution amount designated to such accruable account are disclosed. The accruable account may be used to reimburse the member for qualified medical expenses, and the member may pay any premium shortfall using a tax-advantaged process such as a premium only payment plan. Also disclosed are techniques and apparatus directed to presenting member-specific out-of-pocket expenses for a selected procedure offered by at least one health-care provider.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.13/535,549 entitled “Health Plan Management Method and Apparatus” filedJun. 28, 2012, which is a continuation of U.S. application No.12/576,985 entitled “Health Plan Management Method and Apparatus” filedOct. 9, 2009, now U.S. Pat. No. 8,214,230, which is a division of U.S.application Ser. No. 09/990,123 also entitled “Health Plan ManagementMethod and Apparatus” filed Nov. 21, 2001, now U.S. Pat. No. 7,624,026,which claims priority benefit under 35 U.S.C. §119(e)(1) to U.S.Provisional Application No. 60/252,518, filed Nov. 21, 2000, namingAlbert R. DiPiero and David G. Sanders as co-inventors, and entitled“Competitive Reimbursement Pricing Engine and Applications forProfessional Services Providers, Payers and Consumers,” all of which areincorporated herein by reference in their entirety.

TECHNICAL FIELD

This invention related to health plan management systems and processes,and is particularly concerned with techniques for presenting andmanaging medical reimbursement and out of pocket expenses for a memberof a health plan.

BACKGROUND

Currently, insurance carriers reimburse providers and suppliers ofhealth care or medical services and products based on contractsestablished between the insurance carrier and the provider/supplier.Today's standard contracts do not permit the providers/suppliers todynamically change their prices in a way that changes the reimbursementthey receive from the insurance carrier. Today providers and supplierscannot translate differentiation in service, quality or selection intovariable reimbursement from insurance carriers because reimbursement islocked in for extended periods and the contracts forbid providers andsuppliers from billing the customer of the insurance carrier for morebeyond what is agreed to in the contract with the insurance carrier.

Furthermore, currently no method exists for a consumer to determineimmediately his out-of-pocket expenses for a range of healthcareproducts and services across a range of providers and suppliers.Instead, a claim must first be adjudicated, reconciled against theconsumers benefits plan, out of pocket maximum, and deductible. Nor caninsured customers compare healthcare products and services and judgethem based on their individual out of pocket expenses that integratesinsured and non-insured payment streams. Likewise, today no methodexists for providers and suppliers to change their reimbursement ratefor covered services immediately and allow customers to see thosechanges in terms of their out-of-pocket obligations.

Further still, conventional employee-funded healthcare spending accountswhich use pre-tax employee funds in compliance with US law andapplicable Internal Revenue Service regulations, commonly known asFlexible Spending Accounts (FSA), fall short of being a truly effectiveand economically sound vehicle for handling qualified medical expenses(QME) as defined in section 213 of the Internal Revenue code. They donot permit plan participants to act as normal consumers. Instead FSArules force the participant to predict exactly his healthcare expensesfor a 12-month period and punishes the participant, through theuse-it-or-loose-it rule, for spending less than predicted so theincentive is to spend all the money before the end of the year.Budgeting too little also hurts the participant, since he/she can nolonger gain tax-advantaged payment for qualified medical expenses whichexceed the budgeted FSA amount. Moreover, there's a perceived“overcomplexity” of management: the current accounts do not provide foremployer or employee a simple method of managing healthcare expenses.

Thus today, employers are searching for new benefits solutions that helpattract and retain employees while also controlling healthcare expenses.The current generation of health spending accounts fails to meet theseexpectations for these aforementioned reasons.

SUMMARY OF THE INVENTION

To address these and other perceived shortcomings, one aspect of thepresent invention is directed to managing contributions to an accruablehealth spending account in an employer-sponsored plan offering a memberan employer-funded defined contribution, at least one insurance premiumoption and the ability to specify an allocation of the definedcontribution for payment of option premiums and, in turn, a directedcontribution amount designated to such accruable account. Consistentwith this aspect, the accruable account may be used to reimburse themember for qualified medical expenses, and the member may pay anypremium shortfall using a tax-advantaged process such as a premium onlypayment plan. This aspect may be extended, for example, to processes forfunding such an accruable account. This aspect may be implemented inserver-client architecture, or in another general or specific purposeinformation processing system.

Another aspect of the invention is directed to presentingmember-specific out-of-pocket expenses for a selected procedure offeredby at least one health-care provider. Consistent with this aspect,calculation of such out-of-pocket expenses may take into account datacorresponding to the specific member, such as lifetime-maximum data,yearly out-of-pocket maximum data, deductible data, copay data, andcoinsurance data. Also, consistent with this aspect, out-of-pocketexpenses may be calculated with reference to raw provider-supplied costdata or health plan data.

In yet another aspect of the present invention, alternative proceduresmay be highlighted upon request when appropriate in light of theprocedure under scrutiny, benefits structure information includingmember-specific and health insurance data and costs.

BRIEF DESCRIPTION OF THE DRAWINGS

Additional aspects and advantages of this invention will become apparentfrom the following detailed description of embodiments thereof, whichproceeds with reference to the accompanying drawings, to which:

FIGS. 1 & 2 diagrammatically illustrate accruable health spendingaccount establishment and management according to a first embodiment ofthe invention;

FIG. 3 is a flow chart detailing contribution processing of an accruablehealth spending account according to a second embodiment of theinvention;

FIG. 4 is a sample client display consistent with contributionprocessing described in the embodiment of FIG. 3;

FIG. 5 is a flow chart illustrating qualified medical expense processingaccording to a third embodiment of the invention;

FIG. 6 is a sample client display consistent with qualified medicalexpense processing as described in the embodiment of FIG. 5;

FIG. 7 is a flow chart depicting provider database informationprocessing according to a fourth embodiment of the invention;

FIGS. 8 a and 8 b together are a flow chart describing out-of-pocketexpense processing according to a fifth embodiment of the invention;

FIGS. 9 and 10 are sample client displays illustrating selection ofhealth procedures and comparative out-of-pocket expense processing inaccordance with the embodiment shown in FIGS. 8A and 8B;

FIG. 11 is a flow chart depicting alternative procedure processingaccording to a sixth embodiment of the invention;

FIG. 12 is a sample client display indicating alternative proceduresaccording to the embodiment shown in FIG. 11;

FIG. 13 is a representative client-server architecture consistent withthe disclosed embodiments of the present invention;

FIG. 14 is a functional system diagram consistent with the disclosedembodiments of the invention;

FIG. 15 is a software architecture diagram consistent with the disclosedembodiments of the invention.

DETAILED DESCRIPTION OF THE EMBODIMENTS

An accruable health spending account or health freedom accountconsistent with the disclosed embodiments of the invention is compliantwith IRC §105. In particular, this accruable account (shown in FIG. 1 asaccruable account 230) has the following characteristics: 1) it ispresently contemplated to be funded exclusively using employer funds(though such funds can be controlled and allocated by the health planmember as will be discussed hereinbelow); 2) it is presentlycontemplated that withdrawals from the account can only be made againstfunds actually in existence in the account at the time of withdrawal; 3)such funds can be withdrawn only for the payment of submitted qualifiedmedical expenses as defined in IRC §213; and 4) funds remain in theaccount whilst the corresponding health plan member remains eligible toparticipate in the plan which has the benefit of potentially being ableto accumulate and roll-over funds from year to year (in stark contrastwith conventional employee funded IRC §125 flexible spending accounts).

Accruability is believed an important component in controlling risinghealthcare costs because it creates opportunity cost. With an accruableaccount, individuals will now have reason to ask the question, “Am Ibetter off saving or consuming?” Enabling employees or health planmembers to roll forward pre-tax dollars for reimbursement of qualifiedmedical expenses would remove one of the most onerous restrictions ofthe current healthcare spending FSA, the inability to accrue unspentdollars from year to year. The ability to accrue money tax-free woulddramatically increase the attractiveness of healthcare spendingaccounts.

Accruable health spending account establishment and management accordingto a first embodiment of the invention will now be described withreference to FIGS. 1 & 2. At the first stage, the employer offering ahealth plan chooses one or more health plans to offer employees/healthplan members (FIG. 2 stage 300) and then develops and makes a definedcontribution 210 in line with such offerings, the defined contributionhaving a sum certain or relative value as is known in the art (FIG. 2,stage 310 and FIG. 1, stages 200) from which the employee/health planmember may use to make informed health care choices. Then, the memberwill access the employer defined contribution information online (FIG.2, state 320) and will allocate funds between health insurance premiumoption 240 and an employer-funded accruable health spending plan 230created under IRC §105 (FIG. 1, state 220, FIG. 2, state 330) for thatmember.

More specifically, according to this embodiment, the member will selectone or more insurance options offered by the employer, each optiondefining a discrete premium option having an associated option cost. Themember will decide the premium option best fitting his/her circumstances(one or more premium option selections), and will decide how much of theemployer's defined contribution will go towards paying the selectedpremium option 240, otherwise known as a selection allocation 226.Invariably, this selection allocation will be less than or equal to thetotal option cost for the selected insurance premium option(s).

According to the embodiment shown in FIGS. 1 and 2, the remainder of theemployer funds presented in the employer's defined contribution 210(i.e. subtracting the selection allocation 226 from the definedcontribution 210) will go to fund the accruable health spending account230 as a directed contribution amount 225. Alternatively, although notshown in the Figs., the directed contribution amount 225 could be tiedto the option cost, which give the member less flexibility and theemployer more control over the accumulation rates in the accruablehealth spending account 230. In another embodiment, the employer neednot actually maintain funded individual accruable accounts 230 but poolsuch accounts with employer funds as long as balances/credits andreimbursement debits can be maintained as is well known in the art. Thistechnique simplifies account management responsibilities form employerwhile adding little delay to the contribution/reimbursement process.

In the embodiment presented in FIGS. 1 and 2, the directed contributionamount 225 accumulates monthly in the accruable health spending account230 (FIG. 2, state 340). Note, here that the member need not equate theselection allocation 226 with the premium option cost and in fact mayconveniently make up the difference using pre-tax employee funds (FIG.1, state 260) using payroll deductions/transfers (aka member's out ofpocket premium cost) 228 in accordance with IRC §125 premium only plan(POP) guidelines. This has the effect of boosting funds available to themember for qualified medical reimbursement on a rolling basis (as fundsare present in the account, no use or lose requirements).

Under IRS Section 125, the law allows certain group insurance premiumsto be paid with pre-tax dollars. By using a POP, dollars used to pay forthe premium are deducted before taxes. This eliminates city, state,federal income tax, Social Security and Medicare taxes on those dollars.Thus members can save 20% to 40% compared to paying the premium usingpost-tax dollars. Employers save the matching Social Security andMedicare tax, and federal and state unemployment taxes, plus worker'scompensation, depending on the state regulations. POP accounts may alsobe used to supplement the employer's defined contribution when theoption cost for the selected option premium exceeds the definedcontribution.

Once funds are available in the savings account 230, they may be used atthe member's election to pay for QME expenses (FIG. 2, state 350, FIG.1, state 250).

Accruable health spending account contribution processing according to asecond embodiment of the invention is deemed appropriate with referenceto the flowchart of FIG. 3 and the sample display of claim 5. Withreference to FIG. 3, health freedom account processing begins at step400. At step 400 display of the employer-defined contribution amount andhealth freedom account status for the particular member is displayed tothe user. This display initiation could emanate from a server command toa client in signal form as is well-known in the art (or could beperformed locally to one information processing device). It should berealized in the flowchart of FIG. 3 as well as other flowchartspresented and described herein, the notation “S” stands for aserver-oriented processing step consistent with client-server generalpurpose computing architecture (an example is shown and described hereinwith reference to FIGS. 13 and 14 e.g. client 1400 in communication withserver 1600 via Apache web server 1630 coupled to firewall 1640 whichthen traverses the internet 1420 to firewall 1410 and LAN 1405), thenotation “C” denotes a client oriented step, the notation “S→C” denotesmessaging, signaling, command or instruction processing initiated by theserver to the client device, and the notation “C→S” denotes messaging,signaling, command or instruction processing from the client device tothe server.

Turning back to FIG. 3, the predicted contribution amount informationcalculated as to difference between the employer-defined contributionamount minus a given premium option cost, may be displayed as well tothe member at step 400. Control thereafter passes to Step 402 in whichdisplay of one or more member insurance options as specified in theemployer-defined contribution amount 210 and employer health plandocumentation is initiated. Control thereafter passes to Step 404 inwhich is initiated for the member to make premium option selection andselection allocation 226 of the defined contribution amount 210 asdescribed above. Thereafter, control passes to Step 406.

At Step 406 the information processing system awaits member input.Referring briefly to the sample client display of FIG. 4, Prompt 500,502 and 506 provide an interface for the member according to the presentembodiment to undertake or investigate certain insurance premiumselection options according to the present embodiment. Further, Prompts504 and 508 allow the member to undertake comparative or side by sideevaluation of medical, dental and other insurance plan and premiumalternatives.

Turning back to FIG. 3, once the selection and allocation informationhas been received from the member, control passes to Step 408 in whichthe directed contribution amount 225 on a given time period basis to theaccruable health spending account is calculated as described above.Control thereafter passes to Step 410. At Step 410, the member'sout-of-pocket premium cost 228 is calculated by subtracting theascertained selection allocation 226 from the option cost received abovewith reference to Step 406. Control thereafter proceeds to Step 412 inwhich the display of the directed contribution amount 225, selectionallocation 226 and the out-of-pocket premium cost 228 is presented tothe member. These can be shown in summary form as depicted by summaries530 and 532 illustrated in FIG. 4 based on differing premium optionscenarios. Control thereafter passes to Step 414. In Step 414confirmation from the member is prompted, the member's selections areconfirmed at the client end at step 416. Control thereafter passes toStep 418. At Step 418 confirmed out-of-pocket premium costs presented tothe member are scheduled for deduction from the member's pre-tax POPaccount or payroll deduction in accordance with Internal Revenue Code§125 as described above. Also, though not shown in the Figure, in theconfirmed directed contribution amount 225 may be scheduled for periodicdeduction from employer funds in accordance with Internal Revenue Code§105 (IRC §105) to the member's accruable health spending account.Control thereafter passes to Step 420 in which on demand, transfer ofconfirmed POP and confirmed selection allocation funds are transferredto the health insurer's premium account and paid according to U.S.Internal Revenue Code and specific health insurer directives, as is wellknown in the art. Processing thereafter terminates naturally.

It should be realized that although current Internal Revenue Coderegulations appear to prohibit employees or members from funding section105 compliant accruable health spending accounts with their own money,it is certainly possible to include such capabilities and within thespirit of the present invention. For example, in FIG. 4, areas 540 and542 of the screen include presentation of health freedom accountcontributions from the member himself or herself (herein zero because ofcurrent IRS regulations). It is contemplated that employee contributionsto the health freedom account would be processed in a manner similar tohow conventional flexible spending account contributions are made, withthe exception that it is intended that the employee contributions wouldroll over and accrue from year to year just as the employercontributions currently do.

Qualified medical expense processing according to a third embodiment ofthe invention is deemed appropriate with respect to the accruable healthspending account 230. With reference to FIG. 5, qualified medicalexpense processing according to the disclosed embodiments begins at Step600. At Step 600, a determination is made whether a given member hasspecified non-default qualified medical expense processing. If so,control passes to Step 630. If not, control instead passes to Step 610,in which given qualified medical expense received is deducted from themember's flexible spending account first, and then deducted from themember's accruable account 230 second (once the FSA account has zeroedout for the year) as indicated in Step 620. Control thereafterterminates naturally.

If, however, in Step 610 a determination is made that the member hasspecified non-default processing for qualified medical expenseinformation, as contained in benefit structure information associatedwith the member or otherwise, control instead passes to Step 630 inwhich deductions are made from the member's flexible spending account orhealth freedom account according to member specification. Processingthereafter terminates naturally as shown in FIG. 5.

It should be noted here that the above-described processing in FIG. 5assumes conventional flexible spending account processing techniquesincluding set aside maximum and deficit payment as is well-known in theart for FSA account. Under current IRS regulations, it is notcontemplated that the accruable account 230 can be managed in a deficitmode, unlike flexible spending account, so funds can only be deducted topay for qualified medical expenses in case of an accruable account 230only when funds are on deposit to pay for such expenses either fully orpartially. However, no technical reason exists for preventing this fromoccurring and could be implemented if the IRS rules change. FIG. 6, inparticular the transaction record 700 shown there and illustrates how aclient device may depict health freedom account transactions involvingthe deduction of qualified medical expenses as described abovereferenced to FIG. 5.

Provider costing information according to a fourth embodiment of theinvention is now detailed with reference to FIG. 7. Processing begins atStep 800 where the provider determines his or her conversion factor tobe applied against a predefined relative scale, such as the well-knownMedicare relative value index. As will be appreciated, doing soessentially establishes pricing information for the procedures that theprovider sets the conversion factors for. Processing thereafter passesto Step 802 in which the provider submits conversion factor informationonline for subsequent storage in a provider database. Control thereafterpasses to Step 804 in which the particular provider's reimbursement ratecalculated based on the conversion factor relative to the relative valueindex utilized by the health insurer. Pricing of the provider'sprocedure and service is thereafter determined in Step 806 bymultiplying the provider's conversion factor by the health insurer'srelative value list of interest. Control thereafter passes to Step 808in which a price list for the provider is generated in the providerinformation data base and presented on demand to members, healthinsurers, employers and other interested parties. Thereafter, providercost processing according to this embodiment terminates naturally.

The Allowable Reimbursement Rate Conversion Factor is determined bysetting the Allowable Reimbursement Rate Conversion Factor at apercentile of the conversion factors in the provider database. In theexample in the FIG. 1, the Allowable Reimbursement Rate ConversionFactor is set at the 70th percentile of the conversion factors in thedatabase, but it could be set at any level.

When a member searches for the price of a particular service or good,the health exchange system calculates the member's exact out-of-pocketprice by reconciling the following variables:

-   -   a. Provider's conversion factor multiplied by the value unit of        the service.    -   b. the value unit is a standardized value scale that compares        the value of all goods and services relative to each other. For        example, one value unit scale that could be used could be the        2001 Relative Value Unit scale from Medicare. However, other        relative value scales could be used.    -   c. The conversion factor multiplied by the value unit gives the        price that that particular provider is changing for that        service.    -   d. The Allowable Reimbursement Rate Conversion Factor may be        above or below that the conversion factor of that particular        provider/supplier.    -   e. If the provider's conversion factor is below the Allowable        Reimbursement Rate Conversion Factor, then the payor will        reimburse the provider/supplier for the full amount of the        change, minus the member's obligation. The member's obligation        is determined by the following variables:        -   1. Member co-insurance        -   2. Member out-of-pocket yearly maximum and stop loss and            where the member is in relationship to the stop-loss limit            at the time the services are rendered.        -   3. Member deductible and where the member is in relationship            to the deductible at the time the services are rendered.        -   4. Other benefit structure limits, restrictions or            variables.

Member-specific out-of-pocket expense calculation according to a fifthembodiment of the invention is now detailed with reference to FIGS. 8Aand 8B. Processing begins at Step 900 (FIG. 8A), in which the healthplan member goes on line and selects provider's specific services orprocedures as depicted in FIG. 9 and at the top of FIG. 10. Thereafterin Steps 902 and 904, the raw costs of services calculated for thespecific providers and type of service or procedure desired prior tofactoring in insurance benefits or spending account or reimbursementaccount processing. This is also typically considered as the absolutecost of service or the gross cost of service.

Turning now to FIG. 8B, processing transitions to Step 906 in which adetermination is made whether the members receive their life timemaximum benefits under their health plan. This information is gatheredby looking at the benefits structure information data base 932. If inStep 906, a determination is made that the lifetime maximum has beenachieved, control passes to Step 908 in which the member'sresponsibility is determined to be the entire raw cost of service. Note,however, that the negotiated or reimbursable cost could be analternative result based on the benefits structure information and/orhealth insurer information, and in particular, the type of costconstraints placed on the service provider. Control thereafter passes toStep 910 in which if the cost of service is perceived as a qualifiedmedical expense under IRC Section 213, the cost of service is evaluatedwith reference to the available amount in the accruable account 230and/or the member's flexible spending account with predence processingas discussed above with reference to FIG. 5. Control thereafter passesto Step 912 in which the true out-of-pocket costs (normalized to accountfor available FSA or accruable account funds) are presented to themember on line and control thereafter terminated naturally.

If, however, in Step 906 the determination is made that the member hasnot reached the life time maximum wall, control instead passes to Step920. In Step 920, a determination is made whether the member has reachedthe yearly out-of-pocket maximum stop loss as defined in the benefitsstructure information for that specific member. If so, control passes toStep 922 in which the health insurer is determined to be responsible forthe entire cost up to the allowable reimbursement rate set by the healthinsurer in negotiation with the provider. Thereafter in Step 924 acalculation is made of the out-of-pocket expense the member will beresponsible for by subtracting the entire reimbursable allowable cost(obtained with reference to the health insurer allowable reimbursementrate as contained in the health insurer database 926) from the entirecost of service. Processing thereafter transitions to Step 910 in whichthe member's flexible savings account and health freedom account arereconciled with the remaining cost over the reimbursable allowance, andStep 912 the out-of-pocket pre-FSA and health freedom accountapplication and post FSA and/or HFA allocation represented to the memberon line. Processing thereafter terminates naturally.

If, however, in Step 920 a determination is made that the member has notyet reached the out-of-pocket maximum, control instead passes to Step930. In Step 930 calculation is made as to what's the member'sout-of-pocket responsibility is, herein equal to all costs exceeding theprovider's reimbursement rate 940 as determined herein plus (costs belowthe provider's reimbursement rate - the remaining deductible fromdatabase 938 of the benefits structure information) multiplied by theco-insurance rate 936 (also contained in benefits structure information932. Member specific FSA and accruable account 230 information 934(again a part of the member-specific information residing in theaforementioned benefits structure information 932). Control thereafterpasses to Step 931 in which realization of the member's out-of-pocketcosts is made with respect to the variable amounts in the member'sflexible spending account and/or health freedom account are reconciled.Control thereafter passes to Step 942 in which the member is presentedwith out-of-pocket costs both pre and post application of FSA andaccruable account processing as described above. Control thereafterpasses to Step 944 where the member may optionally select the procedureand service on line and pricing information. That reservation is storedin health insurance data base 952.

The member may lock in a conversion factor ahead of the time servicesare rendered by contacting the payor through the Internet or otherelectronic process. Rates for various products and services will belocked in for a specified time. For example, office visits andoffice-based procedures could be locked in for 12 weeks, while rates forinpatient and outpatient procedures could be locked in for a differentperiod, say 16 weeks.

Providers/suppliers must accept locked-in rates as the full rate theprovider may charge the member.

Thereafter, in this embodiment, it is contemplated processing willcontinue once the member receives service from the provider in Step 948.Of course, the provider sends the claim after service is rendered to thehealth insurer and indemnifying the member in Step 950 and thereafter inStep 954 the provider is paid based on the allowable rate and if thereis any reservation and price lock in that's calculated with reference tothe health insurance data base 952. Simultaneously in Step 954 theprovider bills the member for the remainder of the balance and standardcollection techniques for collection are employed in order to zero-outthe balance. Out-of-pocket costs processing according to the presentembodiment thereafter terminates naturally.

FIG. 10 shows a sample display of a comparison of different serviceproviders consistent with out-of-pocket expense calculation describedabove with reference to FIGS. 8A and 8B. In this embodiment twopotential service providers are listed on row 1180 of the Fig. Raw costinformation as determined above with reference to Steps 902 and 904 andFIG. 8A, are presented on row 1100. Demographics as well as providersupplied information such as credentials and background are shown onrows 1120 and 1130, respectively. Subjective reviews from other memberscan be recorded, collected and presented as shown on comparative row1140. Other information such as web site info (row 1170), independentratings (row 1160) and public record information such as prior licensingand disciplinary actions (row 1150) can also be shown as is illustratedin FIG. 10.

Still referring to FIG. 10, the member's calculated out-of-pocketexpenses as described above with reference to FIGS. 8A and 8B can beconveniently displayed in a comparative side-by-side format as shown inRow 1100 for the two service providers. In this example because of rawprovider pricing differences and differences in provider participationwith the health insurer, the out-of-pocket costs that the memberreceives with respect to one service provider is different that what heor she may receive with respect to another service provider. So that isdetailed here with reference to Row 1110 in consideration of the rawcosts presented on row 1100. Any number of ways of presenting costsdifferences or other graphic or tabular form may be utilized to presentto the member out-of-pocket cost options available to him or her as theyselect a service provider in service.

Still referring to FIGS. 9 and 10, consider the following example:

Mr. Smith wants to get an initial cardiology evaluation. Mr. Smith has abenefit structure of 80% co-insurance, meaning that his insurance covers80% of the charges of the service up to the Allowable Reimbursement RateConversion Factor. Mr. Smith has not reached his yearly out-of-pocketmaximum, Mr. Smith has no deductible with this plan.

Mr. Smith uses the engine to search for an initial cardiologyexamination (FIG. 9).

Today the Allowable Reimbursement Rate Conversion Factor forcardiologists in this area is set at $50. The relative value unit forInitial Cardiology Evaluation is 10.

Thus the payor will reimburse a cardiologist up to a level of $500 foran initial cardiology visit. Dr. Wumps has set his conversion factor at$40. Thus, when Mr. Smith looks up Dr. Wumps, he sees that an initialcardiology evaluation through Dr. Wumps will be priced at $40×10=$400.

Mr. Smith's out-of-pocket obligation is personalized for his specificbenefit plan: since Mr. Smith has an 80% co-insurance plan, Mr. Smith isresponsible for 20% of the bill=$80.

Dr. Carson has set her conversion factor at $60. Thus, when Mr. Smithlooks up Dr. Carson, he sees that an initial cardiology evaluationthrough Dr. Carson will be priced at $60×10=$600

Mr. Smith's out-of-pocket obligation is personalized for his specificbenefit plan; since Mr. Smith has an 80% co-insurance plan, Mr. Smith isresponsible for 20% of the bill up to the Allowable Reimbursement Rateof $500. Charges above the Allowable Reimbursement Rate are Mr. Smith'sfull responsibility. So, when Mr. Smith examines his obligation forhaving an initial cardiology visit with Dr. Carson, he sees that hisout-of-pocket expense will be (20%×$500)+(the full difference between$500 and Dr. Carson's charge of $600)=$200

By requesting an initial cardiology evaluation, all providers providingthis service will be presented to Mr. Smith based on the parameters Mr.Smith enters (for example: gender, location, price availability).

Alternative health care procedure processing according to a sixthembodiment of the invention is now detailed with reference to theflowchart of FIG. 11 and the screen display shot of FIG. 12. Turningfirst to FIG. 11, processing initiates at step 1200, in which adetermination is made whether one or more alternative procedures to aselected health care procedure is available. This determination is madeconsulting member-specific data presented in the benefits structureinformation (e.g. what second opinion or alternative procedures arerecommended by the member's health insurer) medical rights, comparisonof the member-specific cost information (including raw and pre/postreimbursement account out-of-pocket costs calculated in accordance withprocessing described herein with reference to FIGS. 8A and 8B). Aftersuch inquiry is made, if no suitable processing is available,alternative health care procedure of this embodiment processingterminates naturally.

If, however, it is determined in step 1200 that alternative proceduresdo exist, processing instead transitions to step 1210 wherein the memberis prompted whether they are interested in reviewing alternativeprocedures. If not, processing terminates naturally and discoveredhealth care procedure information discovered in step 1200 is discarded.

If, however, in step 1210 a determination is made that the member doeswant to review alternative procedures available to the member,processing instead transitions to step 1230, in which the alternativesare presented to the user. FIG. 12 provides an example alternativeprocedure notification screen (herein visually displayed on a clientscreen associated with the member) consistent with the presentembodiment including presentation of the selected procedure 1310 withalternative procedures 1310.

The general health exchange system software architecture consistent withthe above-described embodiments of the invention reflects a generaln-tier web system architecture based principally on the Java 2Enterprise Environment (J2EE) available from Sun Microsystems of PaloAlto, Calif. and Oracle database technologies available through theOracle Corporation of Redwood City, Calif. The system is conceptuallydivided into a set of layered subsystems, as depicted in FIG. 15.

Data Storage Layer 1840—this layer provides persistent storage of datafor the health exchange system. Data may be created and modified by thesystem, or it may be imported from external sources (for example, aphysician directory).

Data Access Layer 1830—this layer provides an object-orientedabstraction to the higher layers, and insulates them from details of theunderlying data storage machinery. It also enforces data consistency andaccess control.

Utilities Layer 1820—this layer provides shared components which can beused by multiple services, where there are common requirements. Anexample might be a pricing engine, which takes into account employeecensus characteristics, plan features, etc. and computes prices. Someutilities in this layer will be identified a priori; others will emergeopportunistically during design as common needs are identified.

Services Layer 1810—this layer consists of components for implementingparticular services of the site, where a service is a “mini-application”with its own state data, user interaction flow, and business rules.Examples of services are Member Enrollment and Employer Reporting. Eachservice accesses stored data through the data access layer, and may usecomponents in the utilities layer as appropriate. The services layer1810 includes implementation of external systems interfaces, such as forCRM, financial system, carrier systems, etc. Many services may haveside-effects, such as the logging of transactions, triggering of otherevents, etc.

Presentation Layer 1800—this layer contains a component for everyservice, which performs the actual formatting of displayed data in theclient browser (along with client-side JavaScript, form field handling,etc.). The distinction between this layer and the services layer is thatlayout and style information is restricted to the presentation layer,while application state and control reside in the services layer.

Discussion of the functional components of the health exchangeconsistent with the above-disclosed embodiments of the invention isdeemed appropriate with reference to FIG. 14.

Application server tier 1600, based in part on BEA's WebLogic, providesa shrink-wrapped solution to many of the infrastructure issues that haveslowed the development of distributed applications in the past. With theEJB component architecture, complex deployment issues such astransaction monitoring, fail-safe operation, security and scalabilityare handled at the server level, allowing developers to concentrate onlyon implementing the required business logic, including processing inaccordance with the above-described embodiments. In addition, theseservers can wrap Microsoft COM objects and automatically integrate theminto its operating environment, opening access to a vast store ofavailable software. The central component of this tier is one or moreapplication servers responsible for implementing the Java Objectarchitecture, WebLogic provides the ready-made infrastructure to supportthe rapid development and deployment of robust, secure and scalableserver applications.

BEA's Object Request Broker (ORB) services resident on the applicationserver tier 1600 allow access not only to remote data objects but alsoto remote software components, such as Javasoft's Enterprise Java Beans(EJB) or Microsoft's COM objects. Access to these remote componentsallows rapid integration of complex applications by capitalizing on thesoftware development efforts of partner ASPs and on their specializedexpertise. Common Object Request Broker Architecture (ORB) allowscomponents to be distributed across disparate platforms, even if theobjects are not written in the same programming language. CORBAmanagement as well as other language specific ORBs are also built in tomany of the leading J2EE application servers. Emerging XML standards andXML processing components as well as the emerging HL7 Version 3CORBA-compliant health information exchange protocol makeobject-oriented data exchange among disparate systems a reality.

The health exchange system consistent with the above-describedembodiments has adopted a Distributed 3-Tier IT Architecture (D3TA).Encapsulating business logic, including defined contribution amountprocessing, accruable health spending account contribution,reimbursement and management processing, member out-of-pocket expenseprocessing, and alternative health care procedure processing asdescribed above in an application tier permits: 1) taking advantage ofreadily available presentation layer applications such as web browsersand client-side GUI applications; 2) taking advantage of the EnterpriseJava Bean (EJB) architecture to provide an off-the-shelf, robust andscalable middleware infrastructure; 3) take advantage of object-orienteddesign-methodology for rapid, high-quality development; 4) takeadvantage of Object Brokerage Architecture (ORB) for applicationintegration with strategic partners and ASPs and to maximize codere-use; 5) take advantage of the Common Object Request BrokerageArchitecture (CORBA) for data integration and language-independentaccess to remote objects and their methods.

BEA's Object Request Broker interfaces with the application objectsthrough their respective CORBA (actually RMI over IIOP which allows forcertain efficiencies in a pure Java environment while maintainingCORBA's language independence for interfacing to non-Java objects)interfaces. The ORB is responsible for establishing and managing theclient-server relationships among the application objects. It is alsoresponsible for locating and instantiating objects anywhere in thedistributed environment in response to object request from theapplication.

Wrapper objects allow interfacing to non-CORBA based legacy applicationsand other non-CORBA ORB systems running either locally or remotely. Byobjectifying the legacy application API, one can seamlessly integratethese 2-tier applications into the D3TA while providing an easymigration path for future replacement of the legacy application. D3TArequires that all legacy applications be able to operate inclient-server mode.

Enterprise Java Beans permits creation of the object model for thebusiness logic and processing consistent with the above-describedembodiments. Java technology can be further exploited by using the JDBCData Access API for database connectivity. It allows the applicationserver tier 1600 to access virtually any tabular data source from theJava programming language.

The Oracle 81 database platform makes up the data-server tier 1610 ofthe health exchange consistent with the disclosed embodiments of theinvention. This tier is responsible for data storage and retrieval. Fromthe application-server tier 1600, the data-server tier 1610 appears as asingle data source with a unified data interface. Note again thatdata-objects can reside anywhere on the network and that wrapper objectscan be used for interfacing with non-CORBA systems as is well known inthe art. Most CORBA implementations allow for direct access to legacyRDBMs, providing pain-free data integration. Also, as is known in theart, technology now exists to bridge the gap that has existed in thepast between the relational database world and the object orienteddesign world, allowing for the desirable separation between componentsand data while allowing relational database development to occur in themanner in which most DBA's are accustomed. TopLink for Java is anexample of a production ready data encapsulation product.

Router tier 1640 and web server tier 1630, as well as third party tiers(CRM processing system 1650, Financial System 1660, and Reporting System1670) and their functions, capabilities and responsibilities are wellknown in the art and can be implemented with well known programmingtechniques. Accordingly, further discussion of the same is omittedherein.

It will be obvious to those having skill in the art that many changesmay be made to the details of the above-described embodiments of thisinvention without departing from the underlying principles thereof. Thescope of the present invention should, therefore, be determined only bythe following claims.

1. A process for calculating member-specific out-of-pocket expenses, ata health exchange system managing the member's health plan, for apredetermined medical service or procedure available from at least onemedical service provider comprising: receiving at the health exchangesystem a selection by the member of the predetermined medical service orprocedure; calculating by the health exchange system a raw cost forperforming the selected predetermined medical service or procedure forat least one medical service provider; determining by the healthexchange system whether the member has received their life time maximumbenefits under the member's health plan; if it is determined by thehealth exchange system that the member has received their life timemaximum benefits under the member's health plan, evaluating thecalculated raw cost for the predetermined medical service or procedureas a qualified medical expense under the member's health plan, whereinthe evaluating includes determining the availability of funds in themember's health spending account or the member's reimbursement accountapplicable to the calculated raw cost; if funds are available,normalizing by the health exchange system, the calculated raw cost toaccount for the available funds, wherein the normalized calculated rawcosts is the calculated member-specific out-of-pocket expense forreceiving the predetermined medical service or procedure from the atleast one medical provider; presenting, by the health exchange system,the calculated member-specific out-of-pocket expense.
 2. The processaccording to claim 1, further comprising: if it is determined by thehealth exchange system that the member has not received their life timemaximum benefits under the member's health plan, determining whether themember has reached their yearly out-of-pocket maximum; wherein if it isdetermined that the member has reached their yearly out-of-pocketmaximum, calculating a difference amount between the calculated raw costand a predetermined allowable cost by subtracting the predeterminedallowable cost from the calculated raw cost; evaluating a positivedifference amount for the predetermined medical service or procedure asa qualified medical expense under the member's health plan, wherein theevaluating includes determining the availability of funds in themember's health spending account or the member's reimbursement accountapplicable to the difference amount; if funds are available, normalizingby the health exchange system, the difference amount to account for theavailable funds, wherein the normalized difference amount is thecalculated member-specific out-of-pocket expense for the predeterminedmedical service or procedure from the at least one medical provider; andpresenting, by the health exchange system, the calculatedmember-specific out-of-pocket expense.
 3. The process according to claim2, further comprising: presenting, by the health exchange system, thecalculated member-specific out-of-pocket expense as zero when thedifference amount is equal or negative.
 4. The process according toclaim 2, wherein if it is determined that the member has not reachedtheir yearly out-of-pocket maximum, calculating: a first amount, whereinthe first amount is calculated to determine a difference amount when thecalculated raw cost exceeds the predetermined reimbursement rate; asecond amount, wherein the second amount is calculated as an amount ofthe calculated raw cost that is equal to or less than the predeterminedreimbursement minus a remaining member deductible; a third amount=(firstamount+second amount)×(a coinsurance rate); determining the availabilityof funds in the member's health spending account or the member'sreimbursement account and applying the determined available funds tooffset the third amount and establish a fourth amount; wherein thefourth amount is the calculated member-specific out-of-pocket expensefor the predetermined medical service or procedure from the at least onemedical provider; and presenting, by the health exchange system, thecalculated member-specific out-of-pocket expense.
 5. The processaccording to claim 4, further comprising: presenting, by the healthexchange system, the calculated member-specific out-of-pocket expense aszero when the determined available funds completely offset the thirdamount.
 6. The process according to claim 1, wherein calculating the rawcost includes multiplying a predetermined conversion factor for the atleast one provider of the predetermined medical service or proceduretimes a predetermined relative value of the predetermined medicalservice or procedure.
 7. The process according to claim 6, furthercomprising: receiving at the health exchange system a locked-inpredetermined conversion factor by the member for the at least oneprovider prior to receiving the predetermined medical service orprocedure, wherein the locked-in predetermined conversion factor islocked-in for a predetermined amount of time.
 8. A process forcalculating member-specific out-of-pocket expenses, at a health exchangesystem managing the member's health plan, for a predetermined medicalservice or procedure available from multiple medical service providerscomprising: receiving at the health exchange system a selection by themember of the predetermined medical service or procedure; calculating atthe health exchange system a raw cost for performing the selectedpredetermined medical service or procedure for each of the multiplemedical service providers; determining by the health exchange systemwhether the member has received their life time maximum benefits underthe member's health plan; if it is determined by the health exchangesystem that the member has received their life time maximum benefitsunder the member's health plan, evaluating each of the calculated rawcosts for the predetermined medical service or procedure as a qualifiedmedical expense under the member's health plan, wherein the evaluatingincludes determining the availability of funds in the member's healthspending account or the member's reimbursement account applicable toeach of the calculated raw cost; if funds are available, normalizing bythe health exchange system, each of the calculated raw costs to accountfor the available funds, wherein each of the normalized calculated rawcosts is the calculated member-specific out-of-pocket expense forreceiving the predetermined medical service or procedure from each ofthe multiple medical providers; and presenting, by the health exchangesystem, each of the calculated member-specific out-of-pocket expensesfor each of the multiple medical providers.
 9. The process according toclaim 8, further comprising: if it is determined by the health exchangesystem that the member has not received their life time maximum benefitsunder the member's health plan, determining whether the member hasreached their yearly out-of-pocket maximum; wherein if it is determinedthat the member has reached their yearly out-of-pocket maximum,calculating a difference amount between each of the calculated raw costsand a predetermined allowable cost for each of the multiple providers bysubtracting the predetermined allowable cost from the calculated rawcost; evaluating each positive difference amount for the predeterminedmedical service or procedure as a qualified medical expense under themember's health plan, wherein the evaluating includes determining theavailability of funds in the member's health spending account or themember's reimbursement account applicable to each difference amount; iffunds are available, normalizing by the health exchange system, eachdifference amount to account for the available funds, wherein eachnormalized difference amount is the calculated member-specificout-of-pocket expense for receiving the predetermined medical service orprocedure from each of the multiple medical providers; and presenting,by the health exchange system, each of the calculated member-specificout-of-pocket expenses for each of the multiple medical providers. 10.The process according to claim 9, wherein if it is determined that themember has not reached their yearly out-of-pocket maximum, calculating:a first amount for each of the multiple providers, wherein the firstamount is calculated to determine a difference amount for each of thecalculated raw costs when the calculated raw cost exceeds thepredetermined reimbursement rate for a corresponding provider; a secondamount for each of the multiple providers, wherein the second amount iscalculated as an amount for each of the calculated raw cost that isequal to or less than the predetermined reimbursement rate for acorresponding provider minus a remaining member deductible; a thirdamount for each of the multiple providers=(first amount+secondamount)×(a coinsurance rate); determining the availability of funds inthe member's health spending account or the member's reimbursementaccount and applying the determined available funds to offset the thirdamount for each of the multiple providers and calculating a fourthamount for each of the multiple providers; wherein each of thecalculated fourth amounts is the calculated member-specificout-of-pocket expense for receiving the predetermined medical service orprocedure from each of the multiple providers; and presenting, by thehealth exchange system, each of the calculated member-specificout-of-pocket expenses for each of the multiple medical providers. 11.The process according to claim 8, wherein calculating each raw costincludes multiplying a predetermined conversion factor for each of themultiple providers of the predetermined medical service or proceduretimes a predetermined relative value of the predetermined medicalservice or procedure.
 12. The process according to claim 8, furthercomprising: receiving at the health exchange system a selection of oneof the multiple providers by the member for providing the predeterminedmedical service or procedure.
 13. The process according to claim 9,further comprising: receiving at the health exchange system a selectionof one of the multiple providers by the member for providing thepredetermined medical service or procedure.
 14. The process according toclaim 10, further comprising: receiving at the health exchange system aselection of one of the multiple providers by the member for providingthe predetermined medical service or procedure.
 15. The processaccording to claim 11, further comprising: receiving at the healthexchange system a selection of one of the multiple providers by themember for providing the predetermined medical service or procedure. 16.The process according to claim 15, further comprising: receiving at thehealth exchange system a locked-in predetermined conversion factor bythe member for the selected provider prior to receiving thepredetermined medical service or procedure, wherein the locked-inpredetermined conversion factor is locked-in for a predetermined amountof time.
 17. A process for facilitating selection by a member of ahealth plan a medical service provider from multiple medical serviceproviders for providing a predetermined medical service or procedure viaa health exchange system for managing the member's health plan,comprising: receiving at the health exchange system a selection by themember of the predetermined medical service or procedure; calculating amember-specific out-of-pocket expense, at the health exchange system,for receiving the predetermined medical service or procedure from eachof the multiple medical service providers, wherein calculating themember-specific out-of-pocket expense includes determining each of thefollowing: a raw cost for performing the selected predetermined medicalservice or procedure for each of the multiple medical service providers;whether the member has received their life time maximum benefits underthe member's health plan; and the availability of funds in the member'shealth spending account or the member's reimbursement account; andpresenting, by the health exchange system, each of the calculatedmember-specific out-of-pocket expenses for each of the multiple medicalproviders.
 18. The process according to claim 17, wherein determiningeach raw cost includes multiplying a predetermined conversion factor foreach of the multiple providers of the predetermined medical service orprocedure times a predetermined relative value of the predeterminedmedical service or procedure.
 19. The process according to claim 18,further comprising: receiving at the health exchange system a selectionof one of the multiple providers by the member for providing thepredetermined medical service or procedure.
 20. The process according toclaim 19, further comprising: receiving at the health exchange system alocked-in predetermined conversion factor by the member for the selectedprovider prior to receiving the predetermined medical service orprocedure, wherein the locked-in predetermined conversion factor islocked-in for a predetermined amount of time.